A First Look at the Patient-Centered Medical Home for Minority Veterans: Implementation and Utilization

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In 2010 the Veterans Health Administration (VHA) began implementing Patient Aligned Care Teams (PACT), a nationwide patient-centered medical home (PCMH) model, designed to transform primary care into team-based care in over 900 primary care clinics. PACT is focused on improving access to care and coordination between primary and specialty care through the use of interdisciplinary teams composed of primary care providers, RN case managers, clinical and administrative staff, and patients. To date, no study in the peer review literature has reported utilization, patient outcomes, or other evaluative metrics by race/ethnicity for PCMH models of primary care. I aim to fill this gap in the literature in this dissertation by testing: 1) whether PACT implementation varied by the percent of minority veterans served at a facility; 2) whether the association between PACT implementation and changes in healthcare utilization differed across individuals of racial/ethnic minority groups; and 3) whether trends in the rate of hospitalizations for ambulatory care sensitive conditions (ACSCs) were similar between Black and White veterans, and between facilities with different racial compositions. The rate of hospitalizations for ACSCs is a key measure of ambulatory care quality. In the first study of this dissertation, I found facilities with higher percentages of minority patients had modestly less effective PACT implementation. In the second study, I found some evidence to support PACT was associated with different changes in healthcare utilization for minorities relative to Whites. Changes in the trends of utilization, when they did occur, were small and racial/ethnic group specific. I did not find evidence of PACT-associated changes in rates of hospitalization for ACSCs or that they differed by a veteran’s race/ethnicity. In the third study, I found the VHA experienced a substantial decline in the Black-White disparity for hospitalizations for ACSCs. The decline in the disparity was a result of the substantial decline within facilities of similar racial composition. Specifically, among medium and high minority facilities the Black-White disparity declined dramatically and was nearly eliminated in high minority facilities. This finding provides some support of moderating role of facility racial composition on the within Black-White disparity. That is, the Black-White disparity within facilities depended on the racial composition of the facility. I also found significant disparities between facilities of different racial compositions, which remained unchanged over time. This dissertation provides some evidence to indicate Whites and minority groups experienced the implementation of PACT differently. PACT was implemented at modestly lower levels in facilities caring for large proportions of minority veterans. However, I did not find that PACT overall was associated with worsening of disparities in hospitalizations for ACSCs, which is a key indicator of primary care quality. The Black-White disparity in the rate of hospitalization for ACSCs improved substantially between 2003 and 2012, although the disparity was not eliminated.